Medicare did not cover outpatient prescription drugs until January 1, 2006, when it implemented the Medicare Part D prescription drug benefit.

Congress authorized Medicare Part D with the heading the "Medicare Prescription Drug, Improvement, and Modernization Act of 2003."

Private insurance companies administer Medicare Part D plans for the government. The government is not allowed to negotiate drug prices with the pharmaceutical companies.

The VA healthcare system negotiates prices with the pharmaceutical companies. The prices are at least 60% lower than the Part D prices.

Multiple plans are offered with increasing premium prices and deductibles each year.

The increases in deductibles are significant. Below are the increases between 2016 and 2017. Most seniors do not pay attention to the increase in premiums, deductibles or coverage because they automatically enroll each year.

They become aware of the changes changes when they go to pay for their medication

 Initial Coverage Limit: will increase from $3,310 in 2016 to $3,700 in 2017.

 Out-of-Pocket Threshold: will increase from $4,850 in 2016 to $4,950 in 2017.

 Coverage Gap (donut hole): begins once you reach your Medicare Part D plan’s initial coverage limit ($3,700 in 2017) and ends when you spend a total of $4,950 in 2017.

In 2017, Part D enrollees will receive a 60% discount on the total retail cost of their brand-name drugs purchased while in the donut hole.

Generally, not all drugs are covered at the same out of pocket cost to the beneficiary. This gives participants incentives to choose certain drugs over others. This is most often implemented—as is the case for drug coverage for those not on Medicare—through incentives to use generic drugs over brand-name drugs.

The incentive is also often implemented via a system of tiered formularies in which some brand-name drugs are less expensive than others and not subject to step therapy.

Generic drugs are less expensive than brand named drugs. Patients learned this quickly. They encouraged their physicians to provide them with a prescription for generic drugs.

When patients buy drugs with Medicare Part D the deductible price is the patients’ cash outlay. However, the Medicare Part D plan charges patients the total retail price of the drug against their donut.

For example if a 90 day supply of a generic drug is $10 and the retail price is $60 dollars, the $60 is charged against the patient’s donut to be added to future purchases.

If patients paid $10 cash already shouldn’t only $50 of the $60 be charged against the donut?

Many generics can be purchased for a cash price or using a discount drug card coupon for $10 without using Medicare Part D and incurring the $60 retail charge against a donut.

Many generics can be purchased for less using a discount drug card coupon than the cash price a senior on Medicare Part D has to pay using Medicare Part D insurance.

It is not uncommon for senior patients to reach their donut in less than a year. At that time those senior patients have to pay 100% (60% in 2017) of the retail price for a drug until they reach $4,950.

The amount is an additional cash price of $1,250.

It was difficult to figure this out before discount drug cards became available.

How do these discount drugs card work and the discount drug card companies make money?

None of these government policy manipulations are to senior recipients of Medicare Part D advantage. They all benefit the middlemen.

A simple solution is to change the Medicare Part D law so the government can negotiate the cost of drugs just as all the middlemen in the Discounted Drug Card industry are negotiating the price of drugs to the advantage of seniors.

Sometimes the discount cards yield different discounts in different pharmacies in the same zip code.

Sometimes the pharmaceutical companies figure out how to combine two medications that are just as effective when taken separately to increase the cash price to senior patients.

These companies do it with FDA approval.

I became aware of the vast price differences recently with two commonly used drugs Dutasterile (Brand name Avodart) and Tamusulosin (Flow Max). Both drugs have been on the market long enough to be sold as generic drugs.

Using the Good RX discount card these are the variation in prices for the combination drug and the drugs sold separately in one zip code.

Dutasterilde +

Tamsulosin 90

Dutasterile 90

Tamusulosin 90

Walgreens

$183.00

$183.08

$113.93

Kroger

$316.98

$45.61

$30.62

CVS

$388.69

$84.63

$58.62

Tom Thumb

$391.85

49.85

$31.85

Albertson

$391.60

$52.60

$31.85

Walmart

$475.10

$398.71

$55.23

Target

$388.69

$388.71

$136.41

Table 1

None of the pharmacies receive an appropriate discount for the combination of Dutasterile plus Tamulosin. Only Kroger’s negotiator received an appropriate discount for the two drugs sold separately. The total price is $76.23 for 90 pills vs. $316.98 for the combination.

However, seniors have run into a problem in shopping for the best price in a neighborhood.

The government provides a bonus to physician practices that have meaningful use electronic medical records.

One criterion for a meaningful use electronic medical record is the electronically ordering prescriptions for patients.

If a patient usually used the Wal-Mart Pharmacy that telephone number would be in the record. The physician’s prescription would automatically be sent to the Wal-Mart Pharmacy. If the physician wrote for the combination for it would cost $475.10. If the physician wrote the prescription for each medication separately in would cost the patient $453.94 as opposed to cost him $76.23 at Kroger’s.

Compounding the complexity of the electric medical records unintended consequence the pharmacist would automatically fill the combination prescription using that senior’s Medicare Part D insurance. It would be much cheaper than the cash price.

The senior would pay only $146.50 for the combination but his donut would be charged the full retail price of $475.10.

The physician’s office should be aware of the difference in price between the generic combination and the generic drugs sold separately. However, that is not the physicians job.

He should be able to give the patient a paper prescription for both the combination and separate medication so the patient would be able to shop for the best price in his zip code if he was so inclined.

Clearly Medicare Part D is a mess and needs straightening out.

The discount drug cards are not the answer on top of the rising Medicare Part D premiums.

Many retired seniors are living month to month on a pension. The Medicare Part D premiums are paid with after tax dollars not pre-tax dollars.

Many seniors simply cannot afford to pay for their medication. If they do not take their medication they will develop complications of their disease.

Medicare Part A and B will cost the government more and become more unsustainable.

A few simple fixes can solve the problems in Medicare Part D that policy makers and congressmen do not seem to be aware of.

Patients must be responsible for their medical care and their healthcare dollars.

It would be nice if the government would help a little with fixes in information and policies that work for senior patients.

In the meantime it is imperative to “Let the Patient Beware.”

The opinions expressed in the blog “Repairing The Healthcare System” are mine and mine alone.

This means only 2,240,000 people signed up in President Obama’s Health Insurance Exchanges.

It also means that there were 11,760,000 new Medicaid or S-Chip patients.

Edmund F. Haislmaier concluded in testimony to congress;

“While the final figures will be somewhat different once the more complete end of year data is available, at this point it is reasonable to expect that

for the three year period 2014 through 2016, the net increase in health insurance enrollment was 16.5 million individuals. Of that figure, 13.8 million were added to Medicaid and 2.7 million were the net increase in private sector coverage enrollment.”

Eighty-five percent of the 2.7 million have pre-existing conditions. Most are receiving government subsidies.

The 2.7 million covered under Obamacare have destabilized the healthcare insurance market so that healthcare costs for businesses have become unaffordable.

No one has even mentioned the cost of this Obamacare folly to the average hard working taxpayers with healthcare coverage from their employers.

Obamacare’s failure to has been devastating.

“The authors also found that nearly half the new Medicaid enrollees met eligibility standards that were in place before the ACA.”

Maybe Jonathan Gruber is right when he said we, the public, are too stupid to know the wool is being pulled over their eyes.

“For all the hoopla about the ACA exchanges, it appears that Medicaid accounts for the lion's share of coverage gains and that many new Medicaid enrollees would have been eligible for that program even if the ACA had never passed.”

Medicaid is a single party payer system (socialized medicine) that works very poorly. It is almost as bad as the VA Healthcare System.

Is this what the public wants? No

America needs a better healthcare system. Hopefully Dr. Tom Price knows what to do replace Obamacare with once he dismantles all of the Obama administrations regulation.

Maybe Jonathan Gruber is wrong.

The general taxpayer may be smarter than Dr. Gruber thinks. Maybe it is the reason the public elected Donald Trump.

The opinions expressed in the blog “Repairing The Healthcare System” is, mine and mine alone.

Diseases such as multiple sclerosis, rheumatoid arthritis, infertility and others high cost conditions are being charged higher deductibles, experiencing more prior-authorization for drugs, an increase in lesser quality substitution drugs, and often no coverage for the drugs they need.

Most of these conditions require long- term expensive medications.

Therefore consumers with these diseases cannot get treated adequately.

For example, a patient with multiple sclerosis might file a $61,000 claim.

Insurers lose money on every MS patient. An incentive is created for insurers to avoid enrolling patients with MS. The insurers then make its healthcare policy unattractive to people with multiple sclerosis.

Obamacare’s subsidy for patients with multiple sclerosis is inadequate for the cost of the disease’s care.

The insurer doesn’t want to loss $14,000 per patient. Patients are not stupid. They find the best coverage at the lowest price,

This insurer suffers high losses. He either leaves the market or decreases coverage. The perverse incentive leads to low quality care.

Patient with multiple sclerosis on Obamacare are not getting high quality healthcare.

Everyone losses. The government loses, the insurer loses but most of all the patient loses.

There is a better way to insure these people. In a free market system driven by my ideal medical saving accounts the creation of a high risk pool funded by all participating insurance companies in the lucrative private market spreads the risk to insurance companies and government while providing high quality care to qualified patients.

Politicians must start thinking smart.

The format of previous high-risk healthcare insurance pools was a disaster for all the stakeholders. High-risk pools can be formatted in a way that works for patients and does not contaminate the private market with spiraling insurance prices.

I was profoundly disappointed when The American Healthcare Act was introduced last week. There was immediate rejection by Republicans and Democrats in both the House and Senate.

The mainstream media commentators emphasized the Republicans’ rejections and added their own scornful objections. The mainstream media painted the Republican Party as a party is disarray.

The media was presumably giving a boost to the Democratic Party and Obamacare’s failure.

Both Paul Ryan and Dr. Tom Price gave complete explanations of their strategies on how this bill, along with its two other components, will repeal and replace Obamacare.

I was profoundly disappointed in the bill until I was able to hear Dr. Tom Price and Paul Ryan’s explanation of their reasons for the initial reconciliation bill and the plan of the other two components necessary for replacement.

Vice President Pence and President Donald Trump then repeated Ryan ad Price’s strategy in less detail.

By that time there was so much mainstream media noise and politician noise that It was impossible to hear what Tom Price and Paul Ryan were trying to say.

No one listened to what President Trump was trying to say. They were only listening to the media describing Republican caucus’ members outburst against the bill.

President Trump tweeted “it is a beautiful healthcare bill. Everyone will be happy with the result.”

No one listened. No one heard.

The mistake Ryan and Price made was that in the initial introduction of the bill they were being too cute, cunning and clandestine. In reality they were very prepared. They have been working of this repeal and replacement since 2010.

The plan to repeal and replace Obamacare has three parts.

Reconciliation

Administrative Action

Additional Action

It would be very helpful to understand their positions if you watch them explain their positions in their entirety.

This lecture by Paul Ryan is an excellent review of the metodology necessary to Repeal and Replace Obamacare

Both videos are a must see in order to understand the Trump administration and congressional leadership strategy.

Obamacare was supposed to provide an opportunity for people in the individual insurance market to buy healthcare insurance at an affordable price. It was not meant to affect the employer provided healthcare insurance market.

This was supposed to be done by State Health Insurance Exchanges that would supply this insurance. Much of the individual market would be subsided by the federal government..

Only 22 states signed up and most have failed after receiving over $200 billion dollar loans to cover startup cost. These state health insurance exchanges are never going to pay back the federal loans.

Additionally, Obamacare extended Medicaid coverage by increasing the poverty levels in states. This increased the eligibility for patients to participate in Medicaid.

President Obama completely ignored the fact that Medicaid was a financially unsustainable subsidy that was failing rapidly.

Thirty-three States signed up for this expanded Medicaid coverage because they were afraid to get stuck with the bill.

All states are supposed to have balanced budgets. Most states have budget deficits.

They share the costs of Medicaid with the federal government to provide free healthcare coverage to the poor.

President Obama said he would pay 90% of the Medicaid bill. He then increased it to 95% and then 100% in the first few years in order to induce states to join.

Remember, President Obama’s ultimate goal was to have the federal government be in total control of healthcare with a single party payer system.

Twelve million new people have signed up for Medicaid under Obamacare. Additionally new immigrants have been added to the Medicaid roles.

Only nine million have signed up for Obamacare through the health insurance exchanges. Most of the enrollees have preexisting illness.

Most of the enrollees cannot afford the premiums even though President Obama provides subsides to 85% of these people.

Additionally, these enrollees cannot afford the deductibles that are up to $6,000 in some states.

Obamacare has affected the employer market. Obamacare does not pay the insurers enough or have a high enough enrollment distribution to give the insurance industry a high enough return on investment.

Insurers compensate by increasing insurance rates in the employer sponsored private market in almost all of the states. The industry increased rates in both individual and employer sponsored private market by as much as 116% in Arizona.

This forces small and large employers to decrease insurance coverage for employees.

If they did not provide healthcare insurance many small businesses had to pay Obamacare’s mandated penalty.

A mandated penalty was avoided if people worked less than 29 hours a week. Therefore, large employers reduced full time jobs to part time.

There are many other reasons that Obamacare has failed. It has inhibited economic growth.

Obamacare must be completely repealed.

The Ryan plan’s process is repealing as much of Obamacare as it can through the reconciliation process. This is only the first stage. does.

After passage of the American Healthcare Act, Dr. Tom Price will then move on to part two.

He will repeal all the administrative rules and regulations that President Obama and Donald Berwick put in place that hurt Americans and the economy.

He will replace them (one regulation for two eliminated) that will help people obtain affordable healthcare insurance and help our economy grow.

Republicans opposed to the Ryan plan do not seem to get this point.

If Republicans could get total repeal through the House of Representatives with they would not get the 60 votes necessary to get Senate approval.

In stage three Republicans will be able to get the 60 votes necessary for Senate approval.

There are 18 vulnerable Democratic senators up for reelection in 2018.

With Obamacare’s rules and regulations repealed at that time, Democrats’ opposition to things like expanded Health Savings Accounts, malpractice Reform, insurance Reform and insurance across state lines will melt. It will be important for these vulnerable Democrats to vote for these reforms in order to get reelected..

The Ryan plan now looks like an excellent strategy to me. I do not see why the opposition Republicans cannot see it.

Doing it their way with complete repeal a stage one might not work. Then will be stuck with Obamacare and the loss of both Republican controlled of the house and senate in 2018.

There are still refinements necessary to be a consumer driven healthcare plan that is patient-centered.

I hope the Ryan/Price plan is passed by congress.

The opinions expressed in the blog “Repairing The Healthcare System” is, mine and mine alone.

The bill continues to allow the government and the healthcare insurance companies to drive the cost and the healthcare system.

The Republican bill does not provide incentives for consumers to use their healthcare dollars wisely.

It does not include malpractice reform.

If President Trump buys the nonsense Republicans are calling a repeal and replacement for Obamacare, then the RINO’s have pulled the wool over his eyes.

It would be a gigantic mistake to push this bill in its present form. You would be producing political capital for the politically bankrupt Democrats.

This bill is a typical bait and switch. Rand Paul is correct. It is Obamacare lite.

It does not put consumers in charge. It keeps the healthcare insurance industry in full control of medicine, healthcare and the government.

Rather than discontinuing an entitlement it creates another one.

Refundable tax credit is another term for redistribution of wealth. You give money to everyone. You then take it back from some and let the others have it.

It does not repeal most of the Obamacare regulations.

It extends many of the programs past 2019.

President Trump, it does not help drain the swamp as you promised. It makes the swamp worse.

The insurance companies are not returned to a free market. It is a clever way to support the insurance companies by switching from a mandate and penalty to a tax credit (giving the money away to everyone).

This is another entitlement to further enrich the healthcare insurance industry.

Americans elected these Republican politicians to drain the swamp. This bill is no different than Obamacare.

“Refundable” tax credits – for those who don’t owe taxes – are still a subsidy. It is still redistribution of wealth, with winners (those who get the subsidy) and losers (those who pay for it). And the chief winner is the “health plan.” It gets money; the supposed beneficiary may get nothing, or only rationed care from a narrow network.

It is trying to generate doubt about the wisdom of his replacement bill for Obamacare with the following statements that the public doesn’t understand.

2. He will force reimbursement tied to outcomes and related value-based models.

3. He wants doctors in control of the healthcare system

4. He wants tort reform.

5. He wants doctors paid from insurers with fewer hurdles and less barriers.

The healthcare insurance companies are terrified of the abbreviated blueprint. The blueprint represents a threat to the healthcare insurance industry’s power over the healthcare system in both the government and the private insurance sectors.

The mainstream media is babbling about a lack of harmony in the Republican Party. In the next few weeks we are going to hear how disorganized the Republicans in congress are.

Democrats claim the Republicans do not have anything better than Obamacare. They are starting to make up stories about what the Republicans do or do not have. Everything is designed to make the public nervous about President Trump and his administration. These stories are parroted by the Democrat’s ally, the mainstream media.

Meanwhile, the Democrats, the mainstream media, and the public do not know what will be in the replacement act after Obamacare is repealed.

President Trump. Paul Ryan and Tom Price know if all the details are released now most of it would be attacked out of context by the mainstream media.

The Democrats’ goal would be to make the public uncertain about the Republican replacement bill. The Democratic ally, the mainstream media, is all ready spreading the misinformation about the replacement without knowing what is in it.

I even saw a poll published in the mainstream media that said more people like Obamacare than don’t like it.

This is a fake poll. It does not represent the sentiment of the majority of the people.

The political chicanery on the part of the Democrats and the biased mainstream media can be overwhelming.

I do not think the political chicanery is going to overwhelm the public, President Trump or Paul Ryan. I believe they have figured out the Democrats and the media.

Some Republicans have a slightly different opinion on how Obamacare should be replaced. Political action groups oppose some of the methodology being used to replace Obamacare.

“They also are deeply opposed to a commitment to temporarily maintain an expanded form of Medicaid, as numerous GOP governors are demanding.”

Paul Ryan is trying to transition out of Obamacare so that the 11 million new Medicaid patients and the 9 million Obamacare patients do not lose their insurance as the new Republican plan is put in place. Someone does not understand the word temporary.

Several in congress want immediate repeal and replacement. I believe this will give the Democrats more fuel for the fire to subvert anything Republicans are trying to accomplish.

“To the extent that they’re doing something else with this plan other than full repeal, the concerns that conservatives in the House are expressing are completely valid,” said Michael Needham, chief executive of Heritage Action.”

It is important to remember that190 million Americans and their families receive healthcare insurance from their employers. Obamacare has negatively affected employers. The increases in costs, access, deductibles and coverage provided by employers have negatively impacted employees.

Both are demanding relief. These people, at town hall meetings, have made it clear to the Republican congressmen and Senators not to slow down Paul Ryan and President Trump. They want relief and they want it fast.

I believe President Trump will help Paul Ryan get a bill through congress that will provide relief for the entire population.

Hopefully, they have included some of my suggestions.

I am certain that Republicans will work out their differences before they present the bill to the people and the congress.

It the meantime I would suggest that Republics and Democrats keep the noise of the demagoguery down.

The United States of America desperately needs a financially sustainable healthcare system that will provide everyone with access to affordable healthcare.

I have a feeling most people do not know what physicians mean by patient-centered healthcare.

The true definition is that patients are in the center of the medical care interaction. Patients determine their needs and their physicians. Patients drive the medical encounter. Neither the government nor the insurance industries drive the medical encounter.

A fatal floor in Obamacare was that President Obama wanted the federal government to control the healthcare system.

President Trump’s goal is to have patients in control of their own health and healthcare dollars. It is not a problem if the government or employers provide those healthcare dollars.

I believe Tom Price M.D. understands that the only system that will work is a system in which the consumers (patients) are responsible for their own health and healthcare dollars.

The government’s job is to provide incentives in the healthcare system for consumers to become responsible for their health and healthcare dollars.

I am not at all sure the Republican congressional leadership understands the definition or value of patient- centered care.

Obamacare provided just the opposite. Obamacare provided incentives for consumers/patients to be dependent of government.

This fundamental tenet of patient-centered care was tested by Stewart, et.al. in 2000.

Experts studied audio taped doctor-patient interactions while patients also rated these same interactions.

Expert opinion could not be correlated with positive results, but patient-perceived patient-centered care correlated with “better recovery from their discomfort and concern, better emotional health.

Most of the Republicans are talking about patient centered healthcare. However, they start and end with Health Savings Accounts and Consumer Driven Healthcare.

The American Association of Clinical Endocrinologist defined patient-centered healthcare in its diabetes guidelines of 1996 and 2002. (on request)

The guidelines were a System of Intensive Self-Management of Type 2 Diabetes Mellitus.

The Type 2 Diabetic was taught to become a “professor of his/her diabetes.”

The goal was to get the diabetic blood sugar as close to normal as possible. It was shown that normalizing the blood sugar helped avoided the vascular complication of diabetes. The treatment of the vascular complications of diabetes absorbed 80% of the money spent on diabetes.

Patients live with their disease 24/7. Blood sugars are very variable. Patients need to learn how to adjust to these variables by managing their medications and lifestyle.

Patients taking a pill or a shot will not control their blood sugar unless they understand the medication and how to adjust it to have the greatest affect on the blood sugar.

The only way a patient can understand how to control their blood sugar is for them to understand how their blood sugar affects the effectiveness of the medication and how their medications and lifestyle affects their blood sugar.

This same phenomenon applies to most chronic diseases.

The only way to decrease the complications of chronic diseases is for patient to drive the treatment of their disease.

This in turn will be the only way to control healthcare costs. This is what I mean when I say patients should be in control of their health.

As an added incentive to control costs, patients should be in control of their healthcare dollars so they figure out how to use medication most affectively.

“In 2001, The Institute of Medicine published a book called Crossing the Quality Chasm: A New Health System for the 21st Century.”

“In it, the institute identified six aims for improvement of healthcare delivery, one of which was “patient-centered care,” defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.”

The Institute of Medicine’s definition moves patients’ needs and attitudes toward patients being in the center of care. It does not place them as responsible for the management of their care. It does not include patients’ responsibility for their care.

All four of the endocrinologists got close to the definition of patient centered care. Only Carol Greenlee, MD, FACE, FACP, of Western Slope Endocrinology in Grand Junction, Colorado nailed the definition. Dr. Greenlee is the only physician in private practice.

She said:

“One of the most important things is partnership with the patient and what is called “contextualized” care, which means taking into account a patient’s needs and circumstances, goals and values.

It is also called developing a physician/patient relationship.

Another aspect is moving from the physician being at the center of the care model, with staff working to help the physician (doing tasks for the physician or other clinician such as “rooming” the patient or “scheduling” the patient for the clinician) to the staff also “taking care of the patient” as their job, with different roles on the patient-centered care team (getting the patient in for a needed appointment).

It is doing what is best for the patient (not giving the patient what they want, e.g. pain meds, MRI, antibiotics) or ask for (those things are not often best for the patient, but takes time to discuss through).

It’s taking our best science and knowledge and technology and then adapting it to meet the patient’s unique needs, circumstances, values, and goals.

It requires clearing up misconceptions (such as asking what the patient currently understands about a condition or a test or treatment), helping discuss risks and benefits in the context of that individual patient.

It requires asking not just telling, but it is not dumping everything back on to the patient.

It is taking into account the “work” (the job) of care (self-care that the patient or family need to do) on top of the illness and the rest of life that the patient and their family have to deal with and do (i.e. consideration)

Most clinicians think that they are already patient-centered because they care about their patients.

But that does not mean they provide patient-centered care or practice in a patient-centered approach.

I thought I was patient-centered because I cared but then I had to uproot my mental model to really become patient-centered.”

Republicans and their advisors do not understand the meaning of the concept of patient centered care.

Tom Price M.D. understands the concept of patient centered care.

Without the patient being in the center of the management of his/her care, the healthcare system can never be repaired and will never be financially sustainable.

I hope President Trump gets the concept in spite of the advice from congressional Republican and Democrats. Congress is trying to satisfy all the secondary vested interests. Healthcare is a big business with many secondary stakeholders. They do not want to lose this important profit center.

These stakeholders are better organized than patients or physicians to influence healthcare policy makers.

The primary stakeholders are patients with their head coaches and assistant coaches being physicians and their healthcare team.

Patients must be in the center of the healthcare team because they are the only ones that can influences the cost of medical care.